| CT head without contrast | CPT 70450 | $106.88 |
| CT head with contrast | CPT 70460 | $153.36 |
| CT head with and without contrast | CPT 70470 | $180.34 |
| CT neck with contrast | CPT 70491 | $180.34 |
| MRI brain without contrast | CPT 70551 | $204.15 |
| MRI brain with contrast | CPT 70552 | $282.68 |
| MRI brain with and without contrast | CPT 70553 | $332.8 |
| Chest X-ray single view | CPT 71045 | $26.06 |
| Chest X-ray 2 views | CPT 71046 | $33.75 |
| Chest X-ray 3 views | CPT 71047 | $42.44 |
| CT chest without contrast | CPT 71250 | $106.88 |
| CT chest with contrast | CPT 71260 | $173.08 |
| CT chest with and without contrast | CPT 71270 | $180.34 |
| MRI chest without contrast | CPT 71550 | $233.52 |
| MRI chest with contrast | CPT 71551 | $392.6 |
| MRI chest with and without contrast | CPT 71552 | $368.43 |
| Lumbosacral spine X-ray | CPT 72100 | $40.1 |
| CT cervical spine without contrast | CPT 72125 | $106.88 |
| CT thoracic spine without contrast | CPT 72128 | $3,367.73 |
| CT lumbar spine without contrast | CPT 72131 | $106.88 |
| MRI cervical spine without contrast | CPT 72141 | $198.48 |
| MRI thoracic spine without contrast | CPT 72146 | $5,954.89 |
| MRI lumbar spine without contrast | CPT 72148 | $199.14 |
| MRI lumbar spine with and without contrast | CPT 72149 | $282.68 |
| MRI cervical spine with and without contrast | CPT 72156 | $334.46 |
| MRI lumbar spine with contrast | CPT 72158 | $333.8 |
| CT pelvis without contrast | CPT 72192 | $106.88 |
| CT pelvis with contrast | CPT 72193 | $180.34 |
| Shoulder X-ray | CPT 73030 | $34.75 |
| Humerus X-ray | CPT 73060 | $32.41 |
| Hand X-ray 3 views | CPT 73130 | $37.09 |
| MRI upper extremity joint without contrast | CPT 73221 | $211.18 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $368.43 |
| Knee X-ray 1-2 views | CPT 73560 | $34.41 |
| Ankle X-ray 3 views | CPT 73610 | $37.09 |
| MRI lower extremity joint without contrast | CPT 73721 | $210.84 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $5,954.89 |
| CT abdomen without contrast | CPT 74150 | $106.88 |
| CT abdomen with contrast | CPT 74160 | $180.34 |
| CT abdomen with and without contrast | CPT 74170 | $5,796 |
| CT abdomen and pelvis without contrast | CPT 74176 | $189.79 |
| CT abdomen and pelvis with contrast | CPT 74177 | $7,804.99 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $356.19 |
| MRI abdomen without contrast | CPT 74181 | $5,954.89 |
| MRI abdomen with and without contrast | CPT 74183 | $354.51 |
| Abdominal ultrasound complete | CPT 76700 | $106.88 |
| Abdominal ultrasound limited | CPT 76705 | $924.49 |
| Retroperitoneal ultrasound complete | CPT 76770 | $106.88 |
| Obstetric ultrasound first trimester | CPT 76801 | $106.88 |
| Obstetric ultrasound after first trimester | CPT 76805 | $106.88 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $176.09 |
| Transvaginal ultrasound | CPT 76830 | $106.88 |
| Pelvic ultrasound complete | CPT 76856 | $96.28 |
| Scrotal ultrasound | CPT 76870 | $101.58 |
| EKG tracing only | CPT 93005 | $329.63 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,004.59 |
| Transthoracic echocardiogram | CPT 93307 | $136.66 |
| Stress echocardiogram | CPT 93350 | $185.11 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $59,730 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $31,293 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $21,949 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $37,221 |
| COPD w MCC | MS-DRG 190 | $30,008 |
| COPD w CC | MS-DRG 191 | $30,008 |
| COPD w/o CC/MCC | MS-DRG 192 | $30,008 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $24,493 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $21,949 |
| AMI discharged alive w MCC | MS-DRG 280 | $37,648 |
| AMI discharged alive w CC | MS-DRG 281 | $29,328 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $21,949 |
| Heart failure & shock w MCC | MS-DRG 291 | $35,334 |
| Heart failure & shock w CC | MS-DRG 292 | $25,090 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $21,949 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $38,443 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $21,949 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $21,949 |
| GI hemorrhage w CC | MS-DRG 378 | $29,328 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $29,328 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $28,763 |
| Fractures of femur w/o MCC | MS-DRG 533 | $33,309 |
| Kidney/UTI w MCC | MS-DRG 689 | $29,011 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $21,582 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $38,980 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $26,118 |
| Basic metabolic panel (BMP) | CPT 80048 | $424.28 |
| Electrolyte panel | CPT 80051 | $5.89 |
| Comprehensive metabolic panel | CPT 80053 | $553.35 |
| Lipid panel | CPT 80061 | $11.25 |
| Renal function panel | CPT 80069 | $7.29 |
| Hepatic function panel | CPT 80076 | $6.86 |
| Urinalysis non-automated | CPT 81002 | $2.92 |
| Urinalysis automated | CPT 81003 | $74.06 |
| Glucose quantitative | CPT 82947 | $3.3 |
| Hemoglobin A1c | CPT 83036 | $138.98 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $207.6 |
| Complete blood count with automated differential | CPT 85025 | $6.53 |
| Complete blood count without differential | CPT 85027 | $5.43 |
| Urine culture bacterial | CPT 87086 | $6.78 |
| Urine culture identification | CPT 87088 | $6.8 |
| Tissue exam by pathologist level IV | CPT 88305 | $463.5 |
| Fetal non-stress test | CPT 59025 | $15.78 |
| Upper GI endoscopy diagnostic | CPT 43235 | $334.95 |
| Upper GI endoscopy with biopsy | CPT 43239 | $334.95 |
| Sigmoidoscopy diagnostic | CPT 45330 | $130.67 |
| Sigmoidoscopy with biopsy | CPT 45331 | $328.5 |
| Colonoscopy diagnostic | CPT 45378 | $328.5 |
| Colonoscopy with biopsy | CPT 45380 | $429.26 |
| Colonoscopy with polyp removal | CPT 45385 | $429.26 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $2,398.52 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $1,088.27 |
| ACL reconstruction | CPT 29888 | $3,300.05 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $57,963 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $29,328 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $29,328 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $33,309 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $33,309 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $33,020 |
| Major joint replacement w MCC | MS-DRG 469 | $57,963 |
| Major joint replacement w/o MCC | MS-DRG 470 | $31,293 |
| Laparoscopic cholecystectomy | CPT 47562 | $1,888.85 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $1,888.85 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $31,293 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $31,293 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $31,293 |
| Lap inguinal hernia repair | CPT 49650 | $1,888.85 |
| Vaginal hysterectomy | CPT 58260 | $1,526.99 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $1,888.85 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $3,110.01 |
| Lap salpingo-oophorectomy | CPT 58661 | $1,888.85 |
| OR procedure for obesity w MCC | MS-DRG 619 | $60,043 |
| OR procedure for obesity w CC | MS-DRG 620 | $43,563 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $31,293 |
| Complex cataract surgery | CPT 66982 | $849.94 |
| Cataract surgery with lens implant | CPT 66984 | $849.94 |
| Intravitreal injection | CPT 67028 | $48.45 |
| Vitrectomy mechanical | CPT 67042 | $1,533.49 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $57,963 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $57,963 |
